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A Telemental Health Pilot in an Urban Setting
Jennifer Cox, LCSW-CKelly Willis, LCSW-C
Nancy Lever, PhDAshley Mayworm, PhD
Sharon Hoover Stephan, PhDUniversity of Maryland School of Medicine, Baltimore, MD
Disclosures of potential conflicts• No commercial or financial affiliations. No conflicts to disclose.
Research/Grant Funding: • Substance Abuse Mental Health Services Administration (SAMHSA)• US Department of Education• National Institute of Justice• National Institute of Mental Health• US Department of Health and Human Services, Health Resources
and Services Administration• Maryland Department of Health and Mental Hygiene• Baltimore City Public Schools• Baltimore County Public Schools• Howard County Public Schools• Betty Huse Research Award
Acknowledgements• University of Maryland School of Medicine
– Center for School Mental Health (CSMH)– SMH Programs, Clinicians and Fellows– Families and Students of Baltimore– Dr. David Pruitt, Chair, Division of Child and Adolescent
Psychiatry Director, Telepsychiatry– Dr. Sarah Edwards, Division of Child and Adolescent
Psychiatry Medical Director, Ambulatory Services– Dr. Nicole Gloff, Division of Child and Adolescent
Psychiatry, Assistant Professor, Associate Director of Telepsychiatry
– John Kornak, Former Technology Consultant
Learning Objectives
• Objective One: Participants will be able to list 3 benefits of utilizing telemental health to provide psychiatry services in urban schools
• Objective Two: Participants will be able to list 3 strategies for building rapport when using tele mental health.
• Objective Three: Participants will be able to identify the first three steps when initiating telemental health in schools.
University of Maryland School Mental Health Program (SMHP)
Executive Director: Nancy LeverSenior Advisor: Sharon StephanProgram Director: Michael GreenAssociate Director: Jennifer CoxAssistant Director: Kelly Willis
• Established 1989 in 4 schools– Currently in 25 schools
• Elementary through high school• Mental health promotion, prevention, intervention• Predominantly serving students in general education• Low SES, highly stressed communities, violence exposure,
substance abuse • Licensed social workers, psychologists, counselors,
psychiatrists, and graduate trainees
University of Maryland
What is Telemental Health?
• The use of video teleconferencing to deliver mental healthcare or education at a distance
• Interactions using live audio/video
• i.e. a counselor and a student consulting with a psychiatrist in real time
Psychiatrist
Clinician (and patient/family)
Why telemental health?• Improves access to care
• Timely access to locally unavailable services• Spared burden/cost of transportation• Addresses workforce shortages• Increase access
• Convenience• Cost• Patients like it! • Multidisciplinary team can be in multiple settings and come
together at once• Collaboration better than in-person
Exceptions: Safety concerns, patient refusal
TELEPSYCHIATRY IN MARYLAND:AN EVOLUTION
History of Telepsychiatry in the Division of Child and Adolescent Psychiatry and the Department of Psychiatry 2000-2013
• 2000– Maryland Youth Practice Improvement Committee (MYPIC) – Learning collaborative in psychopharmacology among
professionals at UMB/Hopkins and the State inpatient residential facilities utilizing Tele to integrate the case conferences
• 2008– The recruitment of Brian Grady
~ 50% of his salary funded through MHA – HRSA grant with Mid-shore providers
~ Service component ~ Fused funding model
HRSA (continued)
State of the art technology
Development of Operational manual for sites for both adult and child populations
Development of state Medicaid standards for telepsychiatry
Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 21 MENTAL HYGIENE REGULATIONSChapter 30 Telemental Health Services
Authority: Health-General Article, §10-901, Annotated Code of Maryland
Evolution of Equipment
• Tandberg and Polycom units
• DSL Lines
• Webcam, MOVI and Jabber
• Big screen, desktop, laptop
November 2010 Peak of HRSA
Post HRSA
School Mental Health and the use of Telebehavioral Health
– Prince George’s School Mental Health Initiative (9 schools)
- Consultation Model
– Baltimore School Mental Health Initiative (17 schools)
- Consultation and Collaborative Care Model
– Garrett County
- Consultation, Collaborative and Direct Patient Care Model
Operation and Funding Models That Have Supported the Department Tele Programs
• Tobacco dollars
• DHMH contracts
• HRSA grant
• Contracts with Health Department/Community Health Centers for services rendered
(Remote site buys physician time)
• Limited fee for service
Maryland Governor Approves Bill to Expand Coverage of Telemedicine Provided Services!
Tele reimbursement comparable to in-person
All areas (not just rural)
Effective October 1, 2014
The Maryland Health Care Commission (MHCC) Telemedicine Task Force
The Task Force develops recommendations to expand effective use of telemedicine to increase access to healthcare, reduce health disparities and create
efficiencies in healthcare delivery.
The Task Force divided into the following groups:
Technology Solutions and Standards Group
Financial and Business Model Group
Clinical Advisory Group
Telemedicine Task Force
The Telemedicine Task Force Clinical Advisory Group is identifying innovative telehealth use cases where the use of telehealth can:
1.Have the greatest impact upon populations in need or at risk, high volume disease states, high societal value, and/or preventive care.
2.Be consistent with mandates of the Affordable Care Act (ACA), enhance population health management, support innovative payment models (e.g. Accountable Care Organizations (ACOs), Total Patient Revenue (TPR) hospitals, support the CMS waiver, pay-for-performance, and to reduce re-hospitalizations (reduce readmissions seven percent per year for the next five years)
3.Be implementable, testable, and cost effective.
Future Directions & Projects in the Works
• Evolution of telepsychiatry in other programs– EIP, Addictions, DJS, Psychiatric Emergency Services, Primary
Care/Medical homes
• Expanding use of innovative HIPAA compliant technologies– Cost effective
• Continue evaluation of programs– Clinical and cost effectiveness, patient outcomes
• Program sustainability– Diversification of funding sources
OUR UNIVERSITY OF MARYLAND, SCHOOL MENTAL HEALTH TELEMENTAL HEALTH PROGRAM
University of Maryland
Schools and Students Served
7 Psychiatry
Fellows
22 Mental Health
Clinicians
25 Schools in Baltimore City
3-4 schools per FellowsSERVING
Psychiatry Roles
Crisis Management
Home Visits
Attending IEP Meetings
Presentations to Teachers
Classroom Observation
Mental Status Exams
Psychiatric Consultation
Medication Management
Cross Stakeholder Collaboration
Universal Prevention Activities
Evidence-Based Prevention Groups
Participation in Student Support Team Meetings
Primary Responsibilities
Additional Experiences during Rotation
Can only be Performed On-Site (Not Telepsychiatry)
Meeting with Administrators
Psychiatry Roles
Training Process
- Professional development- Experiencing the school expectations and culture
- At least one in-person visit- Greater appreciation and understanding of structures, policies,
opportunities, and challenges for schools and school-based professionals.
- Increased understanding of school-family-community collaboration
- Impact- 26% of the 31 CAP graduates over the past 5 years remain
affiliated with SMH- 20% continue to work in TMH
3-Armed Program Model
Traditional Model• All psychiatry sessions occur in-person in the school setting• Fellows typically visited each of their assigned school sites at
least 2x a month
Telepsychiatry Only Model• All psychiatry sessions occur using telemental health only• Fellows used Video TeleConferencing (VTC) equipment to
communicate with clinicians, patients and families • Fellows had one in-person visit to the school to observe the
physical location and culture of the school site and to meet the principal/administrator of the school
Blended Model• Fellows conducted sessions both in-person and via tele based
upon a predetermined schedule
Overview of Students Served
Completed intake Attitudes Questionnaire: N = 119
Average age of students served: 10.08 years old
39% Female, 61% Male
Presenting Problem
Depression 21%
Anxiety 18%
Disruptive Behavior 21%
ADHD 50%
Trauma 5%
ODD 4%
Conduct 1%
Other (ex: Adjustment D/O, SA)
11%
Productivity: Sessions Provided
Session Foci*:
– Diagnostic evaluation ~5%
– Establish/help with case conceptualization ~5%
– Initial medical evaluation ~24%
– Ongoing medication management ~68%
– Patient education ~1%
– Case review/check-in with patient ~4%
* Note: 1 session could include more than one session focus, so totals may not sum to 100%
On-Site Sessions (N=355)
65%
Tele psychiatry Sessions
(N=187)
Evaluation Procedures
• Productivity outcomes
– Schools and students served
– # of sessions conducted in-person and via tele and session focus
• Parent/caregiver attitudes about telehealth
– Collected from all parents/caregivers at the beginning of the 2015-16 school year (prior to receiving psychiatry services)
• Satisfaction with services
– Parent/caregiver, student, clinician and fellow satisfaction questionnaires completed
– All completed in reference to 1 session per day (session randomly selected)
How do caregivers feel about telehealth, generally?
83% 80% 80% 80%85% 83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Visit/speak with afamily physician
because my childwas feeling ill
Have an annualcheck-up with afamily physician
(even thoughfeeling healthy)
Speak with apharmacist
Speak with adietician ornutritionist
Speak with apsychiatrist
Speak with anothertype of specialist
I would feel comfortable and have confidence using “telehealth” if I needed to…
Agree/Strongly Agree
How do caregivers feel about telemental health, specifically?
72%
54%
74%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Feel comfortableusing telepsychiatry
at a local clinic
Feel comfortableusing telepsychiatry
at a local church
Feel comfortableusing telepsychiatry
from home
Use telepsychiatry inmy community (e.g.,
clinic, church) ifprivacy was assured
If my child were experiencing any of these problems, I would…
Agree/Strongly Agree
61%
50%
75%
77%
0% 20% 40% 60% 80% 100%
Prefer to visit a MH professional in person (insteadof using telepsychiatry)
Prefer to use telepsychiatry (instead of visiting aMH professional in person)
Use telepsychiatry if it saved me 1-hour travel to aclinic
Use telepsychiatry if it saved me 2-hour travel to aclinic
If my child were experiencing any of these problems, I would…
Agree/Strongly Agree
9%
29%
5%
3%
0% 20% 40% 60% 80% 100%
It probably would not help my child'sproblems
It wouldn't be as effective as in-personsessions
The technology may be toosophisticated
Fear of what others might think
Percentage of Caregivers whom Endorsed Each Concern About Telemental Health
Satisfaction with Services: StudentsScale: 1 = Not at All
4 = A LotTelepsychiatry
Sessions (N = 66)
In-Person Sessions
(N = 143)
I could see the doctor on the screen really well 3.68 (.71) -
I could hear the doctor on the screen really well
3.52 (0.81) -
I was worried about anyone else hearing me 1.52 (.95) 1.42 (.94)
It was easy to talk with the doctor 3.61 (.84) 3.74 (.63)
I could talk about my problems easily 3.50 (.81) 3.38 (1.01)
I understood what the doctor wants me to do 3.67 (.64) 3.70 (.71)
I feel OK about the doctor’s advice 3.68 (.71) 3.80 (.54)
I think my friends and other kids would like the doctor
3.12 (1.05) 3.33 (1.05)
I am willing to go back to this doctor 3.58 (.84) 3.75 (.64)
Students report being approximately equally satisfied across telepsych and in-person sessions, with high satisfaction overall.
Parents/Caregivers SatisfactionScale: 1 = Strongly Disagree
5 = Strongly AgreeTelepsychiatry
Sessions (N = 33)
In-Person Sessions (N = 92)
I could talk comfortably with the psychiatrist 4.73 (.10) 4.75 (.09)
I feel confident that my child’s information was not overheard by others outside the room
4.85 (.06) 4.80 (.08)
I could understand the psychiatrists recommendations
4.84 (.07) 4.78 (.08)
I felt the psychiatrist was comfortable with seeing my child
4.84 (.07) 4.77 (.09)
My child will receive the help that he/she needs because of our visit with the psychiatrist
4.67 (.10) 4.78 (.08)
I would be willing to have my child see a (tele)psychiatrist again in the future
4.70 (.09) 4.79 (.08)
Overall I am very satisfied with the quality of services provided by the psychiatrist
4.70 (.11) 4.77 (.08)
My concerns were addressed today 4.70 (.11) 4.78 (.08)
Parents report being approximately equally satisfied across telepsych and in-person sessions, with high satisfaction overall.
Telepsychiatry Specific Questions: Parents
Overall, parents report that:
• They could see and hear the telepsychiatrist well
• Telepsychiatry helped them to see a psychiatrist sooner
• Telepsychiatry was as good as in-person visits
On average, they are unsure/undecided about whether or not their child would have received psychiatry services without telepsychiatry.
Clinician & Fellow Satisfaction
• Across all satisfaction domains, fellows and clinicians reported high levels of satisfaction
• Fellows and clinicians were approximately equally satisfied with tele and in-person sessions
• Clinicians did report somewhat lower satisfaction in tele sessions in terms of “The ease of using video teleconferencing equipment”
• The following concerns were echoed in focus groups:
– Paperwork inefficiencies
– Video equipment problems
– Difficulty with scheduling
– Inappropriateness of tele with certain clients
Challenges to TMH in Schools
– Significant practice change for providers• Finding private and secure spaces in overcrowded schools• Providing continuity of care over breaks• Appt times should be respectful of “core” classes• Unique considerations for patients and families with special needs
– Not all patients are suitable for telepsychiatryservices• Knowing when to properly refer/utilize other resources
– Technology • lack of infrastructure in schools• Working with other systems- the schools
– Family/Patient Apprehension with Tele– Working out schedules/in-person needs/prescriptions
Ryan Haight Act
NOTE RE: CONTROLLED SUBSTANCES
– Prior to prescribing a controlled substance via TMH, the provider must have conducted an “in person medical evaluation” at least once in the past 24 months.
» See H.R. 6353: Ryan Haight Online Pharmacy Consumer Protection Act of 2008
What does this mean for the SMHP Tele program?
https://www.dea.gov/pubs/pressrel/pr041309.html
https://www.govtrack.us/congress/bills/110/hr6353/text
What have we learned?
• Increased access to care
– Reaching patients in rural and urban communities
• Collaboration and integration with other disciplines
– Therapists, PCPs, school administrators, etc.
• Decreased travel time
• Greater comfort with
technology over time
• Increased efficiency
– 8 patients, 3 sites, 3 hours
Additional Uses of Technology• ACANO
– Video teleconferencing solution which allows several members to join a ‘call’ from anywhere
– Use at inter- and intra- departmental meetings, professional development trainings, school meetings, group consultation, crisis intervention
– HIPAA compliant – may be used for clinical care
Setting up TMH Program: Training Manual
1. Equipment
1. Access to internet
2. HIPAA compliant
2. Training
1. Development of Policies and procedures
2. Psychiatrists and clinicians
3. Legal
1. Consents
2. Applicable Laws
TIPS FOR TELEPSYCHIATRY
TMH Considerations in Schools: School Policies and Structures
• Consider the school calendar and how to provide continuity of care during breaks (e.g., vacations)
– Consider offering appointments during non-school hours
• Appointment times should be respectful of “core” classes
• Psychiatrists should know existing supports to properly refer/utilize resources
Confidentiality and Privacy
• Important issue in TMH
– Transmission of video/audio data
– Audio/visual privacy at patient and provider site
• Technology
– Systems and data storage must be in compliance with HIPAA
Physical Location• The physical space affects the clinical encounter, although the relation to
outcomes is not known.
– Rooms that ensure privacy, visual and auditory
– Rooms that are of appropriate size and set-up to:
• Observe patient during the session including activity in the room
• Minimize over-stimulation (e.g., not conference or exam rooms)
– Rooms with adequate and consistent lighting, preferably natural or emanating on same plane as psychiatrist’s screen view
– Rooms that minimize environmental distractions (e.g., noise, distracting backgrounds)
– Rooms with soft surfaces to minimize auditory feedback (e.g., echo)
• Give feedback to clinician at originating site on the above and make modifications as needed
Therapeutic Space• Establishing a “therapeutic space” can optimize the clinical
experience, although the relation to outcomes is unknown. • Determine all persons in the patient room (e.g., family or staff at
patient site) • Inform and show patients of any persons in the psychiatrist’s room
(i.e. supervisors and medical students)• Have all persons on camera, or if not possible, then scan the
camera around the room to ascertain attendees• Have a few age-appropriate toys available with which the patient
may demonstrate developmental tasks• Avoid excessive, distracting or noisy toys (e.g., legos, lots of pieces,
wind-ups)• Avoid electronics for at least part of the session • Establish eye contact by alternating gaze between screen and
camera• Keep your image on the screen to monitor your body language and
affect
Technical Failures
• Technical problems are inevitable…
• Know in advance the technical support system and how to contact that system if a disruption occurs
• Have a back-up plan at both the provider and patient sites for technical failures that is always available and independent of the internet connection. For example having a cell phone or land line telephone that is not affected by disruptions in internet connectivity
• Share information regarding technical failure and back-up plan with the patient prior to start of treatment
Clinical Experience
• Technical factors to consider include: • Length of the session should be sufficient to
obtain vital signs, laboratory reports, or school information, establish rapport, conduct an optimal interview and examination with child and parent
– Anticipate possible delays in coordinating care at the patient site, and allow for technical problems.
• Usually, telepsychiatry sessions are scheduled for the same duration as in-person sessions. Longer sessions may be indicated.
• The presence of a coordinator at the patient site may help to determine length.
Clinical Experience
• Clinical factors to consider include:
• Eye contact may need to be queried
• Telepsychiatrist must maintain eye contact with both the child and the parent as best as possible, alternating gaze between the camera and the monitor
Building Rapport
• Rapport may require greater animation by the telepsychiatrist and work on the part of the clinician
• Be 110% of yourself• Virtual high fives• Giving a tour of your office• Sharing art work• Dancing/Singing• Singing
• Use clinicians as a resource for background about the patient
such as outside interests/recent events that may assist in rapport building
• Provide summary of patient/family concerns- prepare the session!
Informed Consent
• It is generally accepted that the provision of care through telepsychiatry requires informed consent. Informed consent for telepsychiatry:
• Is obtained in addition to consent for treatment and/or embedded in standard consent
• Is obtained at the start of services
• Is conducted with the patient and guardian in real–time.
• Is compliant with local, regional and national laws regarding verbal or written consent
• Is documented in the medical record at both the patient and provider sites
• Addresses the privacy and confidentiality issues specific to telepsychiatry
• Includes a protocol for contact between sessions
Care in Schools
• Protect the patient’s privacy and confidentiality:– Consider location of the treatment space within the school
– Consider the location of any patient information at the school• Educate staff at the site about protected health information
– Maintain a shadow file at the distant (provider) site, if no EMR
– If patient information must be kept at school, consider the clinician’s office
• Determine how the patient is to receive prescriptions, particularly controlled substances
• Consider how to address care during summer or if school is closed
Questions?
Contact Information• Jennifer Cox, LCSW-C, Associate Director and Clinician,
– University of Maryland, School Mental Health Program– [email protected]
• Kelly Willis, LCSW-C, Assistant Director and Clinician, – University of Maryland, School Mental Health Program– [email protected]
• Ashley Mayworm, PhD, Postdoctoral Fellow– University of Maryland, School Mental Health Program– [email protected]
• Nancy Lever, PhD, Executive Director, – University of Maryland, School Mental Health Program– [email protected]
• Sharon Hoover Steven, PhD, Senior Advisor– University of Maryland, School Mental Health Program– [email protected]
Thank you!
